Provider Demographics
NPI:1154579092
Name:FULTZ, LUBOV MARIA
Entity type:Individual
Prefix:
First Name:LUBOV
Middle Name:MARIA
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13470 SW TULIP CT
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-5017
Mailing Address - Country:US
Mailing Address - Phone:503-621-2806
Mailing Address - Fax:
Practice Address - Street 1:19075 NW TANASBOURNE DR STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5802
Practice Address - Country:US
Practice Address - Phone:503-531-1700
Practice Address - Fax:503-531-1704
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5472124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist